How should I evaluate and manage a male patient with erectile dysfunction when there are no red‑flag symptoms?

Evaluation and Management of Erectile Dysfunction Without Red-Flag Symptoms

Begin by measuring morning serum total testosterone (drawn between 8–10 AM), obtaining a fasting glucose or HbA1c, and a fasting lipid panel in every man presenting with erectile dysfunction, as these tests identify treatable causes and cardiovascular risk factors that directly impact both mortality and quality of life. 1, 2

Initial Clinical Assessment

Sexual History

• Ask specifically about symptom onset: sudden onset suggests psychogenic causes (performance anxiety, relationship issues, depression), while gradual onset points to organic etiology (vascular disease, diabetes, hypogonadism). 3
• Determine whether the problem involves achieving an erection, maintaining it, or both, as this distinction helps differentiate vascular insufficiency from neurogenic or psychogenic causes. 1
• Inquire about morning and nocturnal erections: their presence strongly indicates a psychogenic component and essentially rules out severe organic vascular disease as the primary cause. 1, 2, 3
• Ask about masturbatory erections and whether dysfunction occurs only with specific partners or in certain contexts, as situational ED is pathognomonic for psychogenic etiology. 2, 3
• Quantify severity using the Sexual Health Inventory for Men (SHIM) or International Index of Erectile Function (IIEF) to establish a baseline and track treatment response. 1, 3

Medical and Psychosocial History

• Screen for cardiovascular risk factors: hypertension, diabetes, dyslipidemia, smoking, obesity (BMI >30), family history of premature cardiovascular disease (father <55 years, mother <65 years), and sedentary lifestyle. 1
• Review all medications systematically: antihypertensives (β-blockers, thiazide diuretics, aldosterone antagonists), antidepressants (SSRIs, tricyclics), antipsychotics, and sedatives are common culprits. 1, 4
• Assess for depression, anxiety, relationship conflict, and recent major life stressors, as psychological factors are primary or secondary contributors in most cases. 1, 2
• Quantify alcohol consumption and tobacco use, as both directly impair erectile function through endothelial dysfunction. 1, 3

Physical Examination

• Measure blood pressure and pulse to identify uncontrolled hypertension or cardiovascular instability. 1
• Calculate BMI and measure waist circumference as markers of metabolic syndrome. 1
• Perform a focused genital examination: assess for penile skin lesions, urethral meatal abnormalities, and palpate the stretched penis from pubic bone to coronal sulcus to detect Peyronie's plaques or deformities. 1
• Evaluate secondary sexual characteristics (body hair distribution, muscle mass, testicular size) to screen for hypogonadism. 3
• Digital rectal examination is not required for ED evaluation, though benign prostatic hyperplasia commonly coexists and may warrant separate assessment. 1

Mandatory Laboratory Testing

• Morning serum total testosterone (<300 ng/dL defines deficiency) must be measured in every man with ED, as testosterone deficiency impairs response to PDE5 inhibitors and is independently treatable. 1, 2
• Fasting glucose or HbA1c to diagnose or exclude diabetes mellitus. 1, 2
• Fasting lipid panel (total cholesterol, LDL, HDL, triglycerides) to evaluate dyslipidemia and cardiovascular risk. 1, 2
• If testosterone is low, confirm with a repeat measurement before initiating replacement therapy. 2

Cardiovascular Risk Counseling (Critical for Mortality Reduction)

Counsel every man that erectile dysfunction is an independent risk marker for cardiovascular disease, myocardial infarction, stroke, and all-cause mortality with predictive strength comparable to smoking or family history of MI. 1

• ED often precedes coronary symptoms by 2–5 years, making it a sentinel opportunity for cardiovascular risk reduction. 1, 3
• Men with organic ED should be considered at increased cardiovascular risk until proven otherwise, even without cardiac symptoms or known disease. 1
• Calculate Framingham Risk Score and modify based on ED presence, particularly in men aged 30–60 years where traditional risk calculators underestimate true risk. 1
• Consider resting electrocardiogram in men with hypertension or diabetes (Class IIa recommendation). 1

First-Line Treatment: Lifestyle Modification (Mandatory for All Patients)

Prescribe the following evidence-based lifestyle interventions, as they improve erectile function, reduce cardiovascular mortality by 30–50%, and enhance response to pharmacotherapy: 1, 2, 5, 6

• Complete smoking cessation (reduces cardiac mortality by 36% and improves endothelial function). 1, 2
• Weight loss to achieve BMI <30 kg/m² through caloric restriction and increased physical activity. 1, 2, 6
• Regular aerobic exercise (≥150 minutes weekly of moderate-intensity activity). 2, 5
• Limit alcohol to ≤14 units per week (heavy use directly causes ED). 1, 3
• Optimize glycemic control in diabetic men (target HbA1c <7%). 1, 5
• Treat hypertension and dyslipidemia aggressively, selecting antihypertensive agents less likely to worsen ED (avoid thiazide diuretics and non-selective β-blockers when possible; ACE inhibitors and ARBs are preferred). 4, 5

Testosterone Replacement (When Indicated)

If morning testosterone is <300 ng/dL with compatible symptoms (low libido, decreased spontaneous erections), initiate testosterone replacement therapy, as it improves erectile function, enhances PDE5 inhibitor efficacy, and addresses an independent quality-of-life issue. 1, 2

• Before starting testosterone, obtain baseline hemoglobin/hematocrit and PSA (in men >40 years) to screen for contraindications. 2
• Withhold testosterone if hematocrit >50% or PSA is elevated without urologic clearance. 2
• Counsel that testosterone alone does not reliably resolve ED; PDE5 inhibitors will still be required in most cases. 2

First-Line Pharmacotherapy: PDE5 Inhibitors

Prescribe a phosphodiesterase-5 inhibitor (sildenafil, tadalafil, vardenafil, or avanafil) as first-line drug therapy for all men with ED, regardless of organic, psychogenic, or mixed etiology, as these agents enable successful intercourse in 60–65% of patients and work synergistically with psychosexual counseling. 1, 2, 3, 7

Critical Prescribing Instructions (to Maximize Efficacy)

• Educate that sexual stimulation is required for PDE5 inhibitors to work; they do not cause spontaneous erections. 2
• Instruct patients to attempt intercourse at least 5 times at the maximum tolerated dose before declaring treatment failure, as initial attempts often fail due to performance anxiety. 2
• If the first PDE5 inhibitor fails, trial a second agent at maximum dose before considering treatment failure. 2
• Ensure adequate testosterone levels before or during PDE5 inhibitor therapy, as hypogonadism diminishes drug efficacy. 1

Absolute Contraindication

• Concurrent use of oral nitrates (nitroglycerin, isosorbide) due to risk of life-threatening hypotension. 8
• If a patient on tadalafil develops angina requiring nitrates, at least 48 hours must elapse after the last tadalafil dose before nitrate administration. 8

Relative Contraindications (Defer Treatment Until Stabilized)

• Myocardial infarction within 90 days. 8
• Unstable angina or angina during intercourse. 8
• NYHA Class II or greater heart failure within 6 months. 8
• Stroke within 6 months. 8
• Systolic blood pressure <90 mm Hg or uncontrolled hypertension. 8
• Left ventricular outflow obstruction (aortic stenosis, hypertrophic cardiomyopathy). 8

Psychosexual Counseling (Synergistic with Pharmacotherapy)

Refer to a mental health professional or certified sex therapist for all men with identified psychological contributors (depression, anxiety, performance anxiety, relationship conflict), as psychosexual counseling combined with PDE5 inhibitors yields superior outcomes compared to either modality alone. 1, 2, 3, 9

• Psychotherapy achieves successful outcomes in 50–80% of men with psychogenic ED. 3
• Involve the partner in assessment and treatment planning to improve adherence and reduce relationship-related performance anxiety. 1, 3
• For men with predominantly psychogenic ED (preserved morning erections, situational dysfunction), offer psychotherapy as an alternative or adjunct to medical treatment. 1, 2

Second-Line Therapies (When PDE5 Inhibitors Fail)

If two different PDE5 inhibitors at maximal doses fail after adequate trials (≥5 attempts each), refer to urology for second-line options: 2, 3, 7

• Intracavernosal injection of vasoactive agents (alprostadil, papaverine, phentolamine). 7
• Intraurethral alprostadil suppositories. 2
• Vacuum erection devices. 2

Third-Line Therapy

For refractory cases unresponsive to all medical therapies, penile prosthesis implantation (multicomponent inflatable devices) offers high patient and partner satisfaction rates. 2, 7

Common Pitfalls to Avoid

• Do not treat ED without addressing cardiovascular risk, as this represents a missed opportunity to reduce mortality. 1
• Do not delay testosterone testing in men with low libido or decreased spontaneous erections, as hypogonadism is highly treatable and impairs PDE5 inhibitor response. 1, 2
• Do not assume psychogenic ED requires only counseling; PDE5 inhibitors work for both psychogenic and organic ED and should be initiated concurrently. 2, 3
• Do not switch antihypertensive medications solely for ED without first attempting PDE5 inhibitor therapy, as most men respond despite concurrent antihypertensive use. 4
• Do not declare PDE5 inhibitor failure until the patient has completed at least 5 attempts at the maximum dose with adequate sexual stimulation. 2